CSCC NURC 1104 ~ Exam 1 Questions With Complete
Solutions
Why is temperature rectally avoided?
Potential damage of rectum
Invasive
What knowledge does the nurse need when analyzing an older
adults body temp. reading?
Their baseline vitals to understand what is "normal"
What are the potential effects of smoking and energy drinks on
vital signs?
increased BP
Increased HR
Arrhythmia
Irregular heartbeat
Cardiac palpitations
What is the rationale for the AHA recommendation to use the 2-
step BP?
Obtain accurate reading despite auscultatory gap
What s/s of lower extremity perfusion does the nurse assess for
when the pedal pulse is not palpable?
Foot warm on palpation
Client reports sensation to touch
Client moves toes upon command
Pink in color
,While on morning hospital rounds, the nurse notes the client
respiratory rate is 11. What action does the nurse take
immediately?
Raise bed to fowlers or semi-fowlers
Apply oxygen if order available
Assess for obstructed airway, adventitious breath sounds,
productive cough, restlessness, anxiety, and confusion
Notify HCP
What medical diagnosis may cause a pulse deficit in a client?
Hypotension
What is the purpose of an abdominal binder?
Compression belts that circle the abdomen
Used to augment recovery following abdominal or spinal injury
-support the abdomen,
-maintain intraabdominal pressure,
-improve respiratory function,
-improve mobility
-reduce pain
What is the placement of an abdominal binder?
Closure anterior and to the side
Below breasts and above pubic area
Snug but not too tight
placed directly over skin
clean and dry
How many days does it take for bacteria to grow in a culture?
, 2-3 days
When should culture specimens be obtained?
Prior to initiating antibiotics because they can interrupt the
growth of organsims.
When is the best time to obtain a specimen?
In the morning, before breakfast
What tools are needed to obtain a specimen?
Swab, Pen light, tissues, tongue depress
What position is the client placed in for obtaining specimen?
upright
What technique is used to obtain specimen from the nose?
Extend the patients head (tilt) to assess for abnormalities
(pulups)
How does the nurse activate the culture medium?
break median liquid
What is the definition of aerobic?
requires oxygen to grow
What part of the wound does the nurse obtain the specimen for
an aerobic culture?
Close to the surface
What is the definition of anaerobic?
absence of oxygen to grow
Solutions
Why is temperature rectally avoided?
Potential damage of rectum
Invasive
What knowledge does the nurse need when analyzing an older
adults body temp. reading?
Their baseline vitals to understand what is "normal"
What are the potential effects of smoking and energy drinks on
vital signs?
increased BP
Increased HR
Arrhythmia
Irregular heartbeat
Cardiac palpitations
What is the rationale for the AHA recommendation to use the 2-
step BP?
Obtain accurate reading despite auscultatory gap
What s/s of lower extremity perfusion does the nurse assess for
when the pedal pulse is not palpable?
Foot warm on palpation
Client reports sensation to touch
Client moves toes upon command
Pink in color
,While on morning hospital rounds, the nurse notes the client
respiratory rate is 11. What action does the nurse take
immediately?
Raise bed to fowlers or semi-fowlers
Apply oxygen if order available
Assess for obstructed airway, adventitious breath sounds,
productive cough, restlessness, anxiety, and confusion
Notify HCP
What medical diagnosis may cause a pulse deficit in a client?
Hypotension
What is the purpose of an abdominal binder?
Compression belts that circle the abdomen
Used to augment recovery following abdominal or spinal injury
-support the abdomen,
-maintain intraabdominal pressure,
-improve respiratory function,
-improve mobility
-reduce pain
What is the placement of an abdominal binder?
Closure anterior and to the side
Below breasts and above pubic area
Snug but not too tight
placed directly over skin
clean and dry
How many days does it take for bacteria to grow in a culture?
, 2-3 days
When should culture specimens be obtained?
Prior to initiating antibiotics because they can interrupt the
growth of organsims.
When is the best time to obtain a specimen?
In the morning, before breakfast
What tools are needed to obtain a specimen?
Swab, Pen light, tissues, tongue depress
What position is the client placed in for obtaining specimen?
upright
What technique is used to obtain specimen from the nose?
Extend the patients head (tilt) to assess for abnormalities
(pulups)
How does the nurse activate the culture medium?
break median liquid
What is the definition of aerobic?
requires oxygen to grow
What part of the wound does the nurse obtain the specimen for
an aerobic culture?
Close to the surface
What is the definition of anaerobic?
absence of oxygen to grow
